EDITOR—Having just performed cystoscopy on a man of 36 who presented with bladder cancer five years ago, I am not reassured by Del Mar's so called evidence based survey of the likely diagnoses associated with occult haematuria.1

The quoted studies are likely to have missed cases of bladder cancer because not all patients underwent cystoscopy. Only 24 of 255 subjects in Ritchie et al's study underwent both upper tract imaging and cystoscopy.2 Among these, two cases of bladder cancer and one of bladder dysplasia (a premalignant condition) were found. The other 231 patients had not been adequately screened to exclude the presence of bladder cancer. There was no mention of long term follow up to confirm the absence of urological cancer in those who did not undergo initial cystoscopy. Similarly, not all of Hiatt and Ordonez's patients underwent a full urological evaluation,3 which prompts doubts about the accuracy of the performance statistics quoted in this paper.

Sultana et al performed cystoscopy and upper tract imaging in all patients referred over one year with microscopic haematuria.4 In those aged over 50, five bladder cancers and one renal cancer were diagnosed in 126 patients. More recently Khadra et al performed full urological evaluation of 982 patients with occult haematuria.5 Altogether 5% had bladder cancer, 4% stone disease, and 0.3% renal cancer.

Current urological training emphasises the importance of obtaining a midstream specimen of urine, upper tract imaging, and particularly cystoscopy in all patients who have haematuria, whether microscopic or macroscopic and whether persistent or not. Flexible cystoscopy can now be performed in minutes under local anaesthesia. I believe that there has to be a very good reason for not performing cystoscopy in patients with occult haematuria as this is likely to lead to missed diagnoses of bladder …